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Getting "Real" with College Students and Tobacco Cessation
The age of 18 symbolizes the passage from childhood to adulthood. It is during this time that young adults enter a unique stage in life characterized by challenging transition. Whether they go into the workforce, college, military, or get married and start a family, young adults are forced to make a transition that is exciting, but also brings with it added stress and pressures. These social forces and life transitions can encourage new or continued tobacco use. In fact, this age group, often defined as adults aged 18 to 24 years, has the highest smoking prevalence among all adults at a rate of 24 percent. The young adult population has not responded to the cessation treatment and delivery methods that have been shown to work for the older adult population, even though many have a strong desire to quit and have made several quit attempts. Innovative strategies, such as web-based interventions, are needed to improve the delivery of cessation services to young adult smokers, and that fit with their unique experiences, needs, and wants. Current web-based interventions have the potential to reach many of these smokers in a cost-effective way, but they often fall short in terms of adherence to the programs, limiting their potential effectiveness. To help address this issue, Larry An, M.D., and his team at the University of Minnesota, developed and tested an innovative online smoking cessation intervention targeted at college students called the RealU. The RealU study contrasted online intervention strategies and rates of participation between a beta (pilot) website and the final version of the RealU website. The initial beta version of the cessation site addressed smoking cessation topics relevant to college smokers, such as short-term health effects, signs of addiction, social smoking, drinking, and stress. During this pilot testing, participating students were asked to complete a number of tasks each week for 5 weeks, including reporting the number of days they smoked and the average number of cigarettes smoked per day. They were also asked to take a quiz that provided personalized feedback regarding smoking habits or cigarette knowledge and make posts to the website discussion board. In addition to these tasks, the site contained interview and blog excerpts from current and former college smokers discussing quitting. The beta site had an open design allowing students to visit any section of the site in any order they chose. What An and his colleagues found during this trial period was that participation in the study dropped significantly during the 5 week period. In week one, 53 percent participated in the online activities that week. In week five, this number dropped to 26 percent. An and his team built the beta website on sound design principles. But after the first week, as An says, "they couldn't even pay people to come back to a website about smoking cessation." They went back to the drawing board. After more focus groups and interviews, they found that for this age group smoking doesn't exist on its own; it is connected to other things in life like friends, fun, stress, and appearance. The researchers figured that they would have a much better chance of engaging these students if they focused on topics that interested them and connected these topics to smoking cessation instead of focusing directly on smoking cessation messages. After the beta test, An and his team changed the format of the website from a basic smoking cessation website to an online college life magazine. The new website, the RealU, presented similar cessation messages as the beta version but did so within the context of daily college life. This approach provided additional attention to topics that interest college students, such as social life, school success, stress, general health while linking back to smoking cessation messages. The RealU site was also modified to have a more linear structure where users were guided step-by-step through specific weekly tasks. Another RealU modification was the introduction of peer coaches who provided weekly proactive personal e-mail support. Each week, peer coaches reviewed participants' information and wrote follow-up e-mails commenting on any positive behaviors from the prior week, encouraged participants to set goals for reducing or eliminating cigarette use, and provided follow-up e-mail messages to individuals who had not yet completed weekly tasks. Another important thing that An and his team realized was that they first needed to establish credibility with this audience before they would listen to any messages. An says, "Being in public health, we want to tell people that they will be less attractive if they smoke. But why would they believe us?" So the researchers spent the first several issues of the online magazine focused on "fun" topics such as dating and fashion. They even created a "dateability" quiz that used the same format and style as online dating questionnaires but added smoking as a criterion. The quiz assessed how "dateable" someone was based on different criteria such as height, weight, neatness, etc. Those who took the quiz were given a score and ways to improve their "dateability" such as grow 6 inches, clean their room, and stop smoking. The difference between the RealU and the beta version is clear. The students in the RealU group were asked to make 20 weekly visits over two semesters. The average weekly student participation in the RealU activities during this time period was an amazing 95 percent (range 89 percent to 98 percent) with no apparent decline over the 2 semesters. In week 20, 15 weeks longer than the beta phase, the participation rate was still at 93 percent. The changes that the researchers made between the beta site and the RealU greatly increased adherence. And although data on smoking cessation outcomes from the RealU randomized trial are forthcoming, results of follow-up surveys, completed after both the beta testing and the RealU phases, suggest that higher levels of adherence may be related to higher abstinence rates. These findings are similar to other research findings that show a positive relationship between the intensity of a behavioral intervention and cessation outcomes. These findings clearly indicate that presenting a smoking cessation intervention as part of a user-friendly online college-life magazine leads to high levels of sustained participation. This approach could be applied to other college health issues such as alcohol and other substance use, physical activity, and nutrition and may prove effective with other populations, such as young adults not attending college, younger adolescents, and older adults. Researchers have issues they focus on, and then they build their interventions around those issues. What An and his team realized was that, "It's not about our issues; its about their issues. You have to give [the audience] what they want. What is interesting to them? What do they care about? It's about first creating something they are interested in, and then focusing on finding a way to connect the message to it." For more information, please see Nicotine & Tobacco Research, Volume 8, Issue S1 December 2006 , pages S7 - S12 or contact Jessica Nadeau at jnadeau@aed.org. Tobacco-Use Telephone 'Quitlines' May Help Dental Patients Kick the Habit A pilot study conduced by researchers at Mayo Clinic College of Medicine in Rochester, Minnesota, shows that dentists may help their patients stop smoking by referring them to tobacco-use telephone "quitlines." The researchers randomly assigned eight general dental practitioners to provide either brief counseling regarding smoking cessation, or brief counseling along with referrals to a tobacco-use quitline for patients who smoked cigarettes. The researchers enrolled 82 patients, 60 of whom were referred to the tobacco-use quitline, while 22 received only brief counseling. After 6 months, 25% of the patients in the quitline group and 27.3% of the patients in the brief-counseling group had given up tobacco use. The abstinence rates increased in those patients in the quitline group who completed more telephone consultations. While 60% of dentists believe their patients do
not expect tobacco-use cessation services from them, nearly 59%
of patients believe that dentists should provide such services.
"By facilitating engagement in a tobacco-use quitline, dental
practitioners can close the gap between patients' expectations
and the current standard of practice," write the authors. This
study suggests that intervention of dentists in prompting their
patients to quit smoking can play a significant role in decreasing
tobacco-related illness and death.
Doctors Want More Quit-Smoking Help for Patients According to a new study, doctors in the United States, while acknowledging the importance of talking to patients who smoke about quitting, have identified a need for more resources that they can use to assist patients and increase patient follow-through with attempts to quit smoking. Based on a survey of several thousand physicians conducted by the Center for Workforce Studies at the Association of American Medical Colleges, on behalf of the American Legacy Foundation, the study found 86% of physicians say they "usually" advise patients to quit smoking, yet few regularly provide extensive assistance to help patients try to quit. For example, only 13% of physicians regularly refer smokers to others for appropriate smoking cessation treatment. Physicians cite limited services and resources as barriers to effective interventions with patients who smoke. They also noted that a lack of patient motivation, limited coverage for services and limited reimbursement for their time spent with patients dedicated to quitting smoking as additional challenges. More can be done to increase the role of physicians. The study found higher rates of physician referrals to quit-smoking resources in states where there is a greater investment in tobacco control programs. Rates of physician referrals to quit-smoking resources were found to be higher in practices that require physicians to ask about whether or not their patients smoke and document their patients' smoking status. The authors of the study recommend several steps
to help prepare and motivate doctors including providing better
information to physicians on available resources and services
in the community, improving the reimbursement for treatment services
and time, increasing the availability of Continuing Medical Education
(CME) on smoking cessation and behavior change, and expanding
medical school curriculum related to smoking cessation and behavioral
change.
Persistent Smokers May Have Higher Risk of Depression Than Never Smokers New research suggests that long-term smokers may be at a higher risk for depression as compared to never smokers. Former smokers also have an elevated risk of depressive symptoms in the short term, however, this risk eventually declines to the level of never smokers. It seems that both a completely smoke-free life style and successful smoking cessation seem to guard against developing depressive symptoms over time. It is known that depression is associated with cigarette smoking, but the nature of this association is discussed under various hypotheses. First, according to the so called self-medication hypothesis, those who suffer from depressive symptoms smoke cigarettes in order to alleviate their symptoms. According to the second assumption, chronic persistent smoking may have a role in the etiology of depression. The third hypothesis suggests that there is a reciprocal mechanism between smoking and depression. The fourth hypothesis says that there are shared underlying genetic factors explaining this co-morbidity. This study, conducted in the Department of Public Health at the University of Helsinki, explored which of those assumptions would be supported by the data. The researchers had access to the data collected within the Finnish Adult Twin Cohort Project. There were about four thousand male and five thousand female twins whose health and health behavior were followed-up through 15 years. The results suggest that first, persistent chronic cigarette smoking predicts depressive symptoms. However, when adjusted for other factors associated with depression, the elevated risk of persistent smoking remained significant among men only. Secondly, there was evidence suggesting that those smokers who had quit had elevated depression risk in relatively short term. The association of quitting smoking and depressive symptoms indirectly support evidence for the self-medication hypothesis. Dr. Korhonen emphasizes, however, the further evidence
within the same study showed that those smokers who had quit successfully,
and remained abstinent through the follow-up, did not have elevated
depression risk compared to the never smokers. He said, "This
may reflect a relatively long recovery process from the adverse
effects of cigarette smoking."
The Impact of Retail Cigarette Marketing Practices on Youth Smoking Uptake In a recent study published in the May issue of The Archives of Pediatric and Adolescent Medicine, researchers found that price-cutting and other marketing strategies widely used by the tobacco industry are highly effective in encouraging children and teenagers to smoke. Researchers used a nationwide survey of more than 26,000 students in 8th, 10th and 12th grades from 1999 to 2003. The study period immediately followed the landmark 1998 settlement in which the tobacco companies agreed to pay the states billions of dollars to resolve smoking-related health claims and to restrict advertising and promotion directed at young people. The scientists found that point-of-sale advertising is associated with getting children to try smoking, but has little effect in encouraging habitual tobacco use. However, cigarette promotions, especially those that involve price reductions, may tempt teenagers who have already experimented with tobacco to become regular smokers. The study's authors estimated that if stores had
no advertising, there would be a decrease of 11% in children who
try smoking. If promotions were eliminated, there would be a decrease
of 13% in the number who become habitual smokers. The researchers
concluded that the industry's emphasis on marketing was offsetting
the benefits of the restrictions imposed by the 1998 agreement.
They also said their findings provided evidence that price increases
and restrictions on price-based promotions would aid public health.
Harmful Secondhand Tobacco Smoke Can Be Detected in Kids as Young as 11 Environmental tobacco smoke has an adverse effect on children as young as 11 years, according to new evidence reported in Circulation: Journal of the American Heart Association. The findings add to the mounting evidence of the harmful health consequences of secondhand smoke exposure in children. "Our study shows that exposure to secondhand smoke can harm the function of the arteries in children, just as other research groups have found that secondhand smoke harms the function of the arteries in adults," said Katariina Kallio, M.D., lead author of the study. Children participating in this study were initially enrolled as infants in the randomized, prospective atherosclerosis prevention trial. Researchers studied boys' and girls' responses to environmental tobacco smoke at ages 8 through 11. Researchers assessed arterial health and objectively measured exposure to environmental smoke through cotinine levels instead of self-reported smoking at home by parents. At age 11, 402 children participated in high-resolution
ultrasound studies of brachial artery measurements. These ultrasound
studies revealed a significantly lowered endothelial function,
a measure of arterial health, in the group of children with the
highest cotinine concentrations. "Even modest exposure to tobacco
smoke alters endothelial function in children, and may impact
early development of atherosclerosis," Kallio said. "Endothelial
dysfunction relative to passive smoking may be only partially
reversible after cessation to the exposure, suggesting the importance
of implementing smoke-free environments for children at home and
in public places."
Better Health More Than Twice as Likely for Nonsmokers Who Live and Work with Smoking Restrictions In the first study of its kind to evaluate how smoking restrictions in the workplace and at home affect health status, researchers at the Mailman School of Public Health at Columbia University found that nonsmokers who live under both a total household and total workplace smoking ban are over two- and a half times more likely to report better health than those without smoking bans. The study surveyed 1,472 Chinese American adults who live and work in New York City. Forty-three percent of respondents reported a total smoking ban at home and the workplace, 20% at work only, 22% home only, and 15% reported no smoking restriction at home or work. Smokers who live under a total household smoking ban only or both a total household and total workplace ban were respectively 1.90 and 2.61 times more likely to report better health status compared with those who reported no smoking ban at work or home. The study confirms that household smoking restrictions are more strongly associated with better health status than workplace smoking restrictions. "As the policy environment continues to move toward comprehensive protection at the workplace, the household increasingly will become the main and perhaps the only significant source of exposure among nonsmoking adults as it is among children," observes Donna Shelley, MD, Mailman School assistant professor of clinical Sociomedical Sciences, director of the Tobacco Cessation Program. Smoking restrictions have a dual goal, to protect
the health of nonsmokers and to increase smoking cessation among
smokers. Since smoke-free public places appear to facilitate the
adoption of smoke-free homes, and as smoke-free air legislation
spreads, a rise in protection from secondhand smoke at home can
be expected. "However, this does not, preclude the need to take
a proactive approach to increasing adoption of household bans,"
says Dr. Shelley.
New Data Show 91% of California Women Don't Smoke California adults are smoking at record low rates, with women smoking far less than men, according to new data released by the California Department of Health Services. Adult smoking prevalence declined to 13.3% in 2006, down from 14.0% in 2005. For the first time since the state began tracking smoking prevalence, rates among California women decreased to a single digit, 9.1% in 2006, compared with 11.1% in 2005. Smoking among California women has decreased by 54% since 1988 - an unprecedented decline. California's new prevalence data bring the state within reach of the national Healthy People 2010 objective to reduce smoking rates to 12%. California Governor Arnold Schwarzenegger's Health
Care Reform proposal calls for expanding access to smoking education
and cessation services to help an additional 40,000 California
smokers quit. In addition, the proposal seeks to double the rate
of smokers using health insurance cessation benefits from an estimated
6% to 12% annually.
IOM Report Shows U.S. Can Dramatically Reduce Tobacco Use The groundbreaking report issued by the Institute of Medicine, Ending the Tobacco Problem: A Blueprint for the Nation, makes it clear that the United States can eliminate tobacco use as a serious public health problem, but the main obstacle to achieving this goal has been a lack of political will, not a lack of proven solutions. A combination of increased excise taxes, nationwide indoor smoking bans, and other measures would significantly lower the U.S. smoking rate, which now hovers at around 21% of the adult population, says the report. But to achieve faster, more certain reductions, the U.S. Food and Drug Administration (FDA) should be given broad regulatory authority over tobacco marketing, packaging, and distribution, and other revisions to current tobacco policy should be enacted, said the committee that wrote the report. The report sets an ambitious, but attainable goal for the nation: "To reduce tobacco use so substantially that it is no longer a significant public health problem." However, the report concludes that current efforts, even if fully implemented, are insufficient to achieve this goal and would be hard-pressed to achieve even the far more modest goal of reducing the adult smoking rate from the current 20.9 % to 15 %. As the report states, such a modest reduction is not satisfactory because tobacco use would continue to cause a significant amount of premature death and disease. The report recommends a two-pronged approach and demands strong and immediate response by elected officials at all levels. Recommendations include:
For more information, see web link: Ending the Tobacco Problem: A Blueprint for the Nation, May 24, 2007
New York City's Success in Reducing Smoking Sets Example for the Nation New York City's dramatic success in reducing smoking, reported in the June 22nd issue of the CDC Morbidity and Mortality Weekly Report (MMWR), sets an example for the nation and shows what can be accomplished when committed leaders aggressively implement proven tobacco prevention measures. From 2002 to 2006, New York City implemented comprehensive tobacco control measures including increased tobacco tax, smoke-free workplaces, and hard-hitting educational campaigns. After a decade with no progress, New York City's smoking rate declined from 21.6% in 2002 to 17.5% in 2006. After the decline stalled in 2005, in 2006 NYC ran a year-long hard-hitting media campaign to motivate more smokers to quit. By 2006 there were 240,000 fewer smokers in New York City than there were in 2002. This reduction will prevent at least 80,000 deaths from smoking-related causes. Nationally, the adult smoking rate has been declining much more slowly and stood at 20.9 % in 2005, the last year for which the Centers for Disease Control and Prevention has publicly reported data. New York City's current smoking rate is the city's lowest on record. That change represents the sharpest drop since the city began keeping records in 1993, and one of the steepest declines in the nation since 1965, when the surgeon general first warned Americans about the dangers of smoking. Young adult smoking (age 18-24) in NYC decreased from 23.8% in 2002 to 15.5% in 2006, the largest decline among reported sub-groups. New York City has succeeded in dramatically reducing
smoking because it is one of the few places that have implemented
the comprehensive approach to reducing tobacco use recommended
by public health experts. New York City has a high tax on tobacco
products, a strong smoke-free workplace law that covers all workplaces,
restaurants and bars, and effective tobacco prevention and cessation
programs that prevent kids from starting and help smokers quit.
New York City's experience provides an important reminder that
continued reductions in smoking require a sustained investment
in prevention and cessation programs, including hard-hitting advertising
campaigns. For more information, see web link:
Lung Association Releases State Legislated Actions on Tobacco Issues The American Lung Association released the 2006 edition of State Legislated Actions on Tobacco Issues (SLATI). This report is a compendium of state tobacco control laws that occurred as of January 2, 2007. The SLATI Web site tracks state tobacco control laws, such as state restrictions on smoking in public places and workplaces and state tobacco taxes, on an ongoing basis. It is the only resource of its kind in tobacco control today, providing up-to-date information on tobacco control laws in all 50 states and the District of Columbia.
New Jersey Senate Panel Supports Penalty for Smoking in Cars With Children Aboard Smoking in New Jersey has been banned from the workplace, public buildings, bars, restaurants and even large swaths of the casino floors in Atlantic City. The next frontier is the family car with children aboard. Under a measure passed unanimously on June 7, 2007 by the Senate Health, Human Services and Senior Citizens Committee, anyone caught smoking while a passenger 16 years old or younger is in the vehicle would be charged with a disorderly offense punishable by a $100 fine. The measure would make smoking with a child in the
car a primary violation of the state's traffic codes, allowing
police officers to stop such drivers and give them tickets. If
approved by the full Legislature and signed into law by Gov. Jon
S. Corzine, the measure would make New Jersey the third state
- after Arkansas and Louisiana - to impose such a ban.
Montana Tobacco Quit Line Boasts High Success Rate The Montana Tobacco Quit Line, a program of the Department of Public Health and Human Services (DPHHS), marked its third anniversary in May while boasting one of the highest quit rates in the nation. Thirty percent of the more than 17,500 people who have called the Quit Line report successfully quitting, according to Linda Lee, supervisor of the Montana Tobacco Use Prevention Program (MTUPP) of DPHHS. The Quit Line reached more than 7,500 Montanans during its third year of operation, a dramatic increase over each of the first two years. The number of spit tobacco users who call also is increasing, Lee said. According to Stacy Campbell, a tobacco cessation specialist with MTUPP, most of the people who call the Quit Line have used tobacco for more than 10 years. "Thanks to the free nicotine replacement therapy and personalized guidance from quit specialists, former smokers and spit tobacco users are now enjoying better health and reduced risk of deadly diseases," she said. The Montana Tobacco Quit Line is the only service
of its kind in the nation that offers three options for nicotine
replacement therapy: gum, patches, and lozenges.
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